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NON-HAZARDOus 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste T a kI Fumf <br /> WASTE MANIFESTtj A7 <br /> 505 -qOO-0305 <br /> )en.egi Nameand M iling Address Genaralor's Site Address(A different than mailing <br /> �4f <br /> Ge;Te a a s ne <br /> 6.Tran an �� U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U1 S.EPA ID Number <br /> S. <br /> Designated Facility Name and Pite Address .� U.S.EPA ID Number <br /> avII ■ylS !��' �'ui��,'LL f/,Al� � J <br /> Facil s Phone: I u� �• � — + <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt.NoL <br /> 1. <br /> cc Vp ,(' <br /> cc <br /> ' V "' ' t <br /> W <br /> Z 2. <br /> W <br /> L9 <br /> 3. <br /> 4- <br /> 13-Special Handling Instructions and Additional Information <br /> ^)4• <br /> 14.GEN ERATOR'SIOFFEROR'S CERTIFICATION.I hereby declare that the contents of this consbgnmsnt are fully and aocuralely described above by the proper shipping name,and are classified.packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable i ational and nalion I governmental regulations. <br /> Genesd yped*JOJAW� <br /> Signal u � Month-?4 .. a , Oay Year <br /> -4 15.International Shipments ❑ ❑Import to U.S. Export from U.S.11.5. Port of entrylexit: <br /> Trans orler Signature fur exports only): Date leaving U.S.: <br /> iZ 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Prinled+Typed Name signal Moni D Year <br /> C - �. 1 ` <br /> a Transporter 2 PrintedlTyped Name signature Month Day Year <br /> H <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> Manifest Reference Number: <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> v <br /> tai Facility's Phone: <br /> m 17C.signature Of Alternate Facility(or Generator) Month Day Year <br /> 4 <br /> 2 <br /> W <br /> 0 <br /> 18,Designated Facility Owner or Operator. ertificat of receipt of materials Covered by the manifest except as din Item a <br /> Printed+Typed Name Signatur Mo e r <br /> 169-BLC-05 11977(Rev.9109) DESIGNATED FACILI TO GENER <br />